Effectiveness of Steroid Nasal Sprays for Grade 4 Adenoid Hypertrophy in a 6-Year-Old Child
Steroid nasal sprays can temporarily reduce adenoid size and symptoms in a 6-year-old child with grade 4 adenoid hypertrophy, but the effect is not sustained after discontinuation of treatment and ultimately adenoidectomy may be required for definitive management. 1
Efficacy of Intranasal Steroids for Adenoid Hypertrophy
- Mometasone furoate nasal spray has been shown to temporarily reduce adenoid size and related symptoms in children with adenoid hypertrophy, with symptom improvement rates of up to 84.6% during treatment 1
- However, after cessation of intranasal steroid treatment, symptoms typically recur, and most children ultimately require adenoidectomy 1
- Histopathological studies show that intranasal mometasone furoate reduces reactive cellular changes and vascularity in adenoidal tissue after one month of use, but longer treatment periods may be needed to assess effects on adenoid size 2
- Fluticasone propionate nasal drops (400 μg/day for 8 weeks) have demonstrated a 35.6% reduction in adenoid-to-choana ratio compared to just 2.2% with placebo 3
Age-Appropriate Intranasal Steroid Options
- Mometasone furoate (Nasonex) is FDA-approved for children as young as 2 years at a dosage of 1 spray per nostril daily (50 μg per spray) 4, 5
- Fluticasone propionate (Flonase) is FDA-approved for children ≥4 years at a dosage of 1 spray per nostril daily 4, 5
- Triamcinolone acetonide (Nasacort Allergy 24HR) is approved for children ≥2 years with a dosage of 1 spray per nostril daily for ages 2-5 years 4, 5
Safety Considerations
- Common side effects of intranasal corticosteroids include epistaxis (nose bleeds), pharyngitis, cough, and nasal irritation 4
- Intranasal corticosteroids at recommended doses have not shown consistent clinically relevant effects on the hypothalamic-pituitary-adrenal axis in children 5
- Studies with intranasal fluticasone propionate, mometasone furoate, and budesonide have shown no effect on growth at recommended doses 5
Clinical Approach for Grade 4 Adenoid Hypertrophy
- For a 6-year-old child with grade 4 adenoid hypertrophy, a trial of intranasal steroids may be considered as a temporary measure, but parents should be counseled that this is unlikely to provide long-term resolution 1, 3
- Mometasone furoate would be an appropriate choice given its approval for children as young as 2 years 4, 5
- The recommended dosage for a 6-year-old child is 1 spray per nostril daily 4
- A treatment course of 8-12 weeks may be attempted to assess response 1, 3
Limitations and Expectations
- While intranasal steroids may provide temporary symptom relief, they do not typically result in sustained reduction of grade 4 adenoid hypertrophy 1
- In a randomized controlled trial, all children who initially responded to mometasone furoate eventually required adenoidectomy by the third month of follow-up after treatment cessation 1
- Parents should be informed that adenoidectomy may ultimately be necessary for definitive management, especially with grade 4 hypertrophy 1
- For children aged ≥4 years with persistent otitis media, adenoidectomy along with tympanostomy tubes has been shown to be more effective than tubes alone 4
Alternative and Adjunctive Treatments
- For children with coexisting allergic rhinitis, intranasal steroids may provide additional benefit for allergic symptoms 5
- Montelukast combined with intranasal budesonide has shown benefit in children with mild obstructive sleep apnea, but there is insufficient evidence for its use in severe adenoid hypertrophy 4
- Intranasal steroids are not recommended as the sole treatment for otitis media with effusion related to adenoid hypertrophy 4, 6
In summary, while intranasal steroids may temporarily improve symptoms and reduce adenoid size in a 6-year-old with grade 4 adenoid hypertrophy, parents should be counseled that this effect is likely temporary and surgical intervention may ultimately be necessary for definitive management.